Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia

Abstract

We have reviewed accidental spinal administration of tranexamic acid. We performed a MEDLINE search of cases of administration of tranexamic acid during epidural or spinal anaesthesia between 1960 and 2018. No reports of epidural administration were identified. We identified 21 cases of spinal tranexamic acid administration. Life-threatening neurological and/or cardiac complications, requiring resuscitation and/or intensive care, occurred in 20 patients; 10 patients died. We used a Human Factors Analysis Classification System model to analyse any contributing factors, and the reports were also assessed using four published recommendations for the reduction in neuraxial drug error. In 20 cases, ampoule error was the cause; in the last case a spinal catheter was mistaken for an intravenous catheter. All were classified as skill-based errors. Several human factors related to organisational policy; dispensing and storage of drugs and preparation for spinal anaesthesia tasks were present. All errors could have been prevented by implementing the four published recommendations.

Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error

“…Our case of maternal death was assessed by independent experts to be due to intrathecal TXA, and occurred in the context of a disturbing international trend. A recent review in Anaesthesia [11] highlighted 21 such cases between 1988 and 2018, 10 of which were fatal. Twenty were due to 'ampoule error' .…”

“…Early cerebrospinal fluid (CSF) lavage is also recommended, following success in the management of similar cases. [11,14,15] CSF lavage consists of removing 10 mL of CSF and replacing this with 10 mL of saline, repeated up to four times. [14,15] The increased mortality rate in the obstetric population following intrathecal TXA is possibly due to decreased CSF volume in pregnancy, leading to increased drug concentrations.…”

“…[14,15] The increased mortality rate in the obstetric population following intrathecal TXA is possibly due to decreased CSF volume in pregnancy, leading to increased drug concentrations. [11] Given the consequences of inadvertent intrathecal TXA administration, is the increased risk justifiable? TXA has become an integral part of the management of OH: the WOMAN trial [4] suggested that a maternal life could be saved with every 267 usages following OH.…”

Spinal tranexamic acid – a new killer in town

“…The article by Patel et al. in this issue of Anaesthesia , highlighting the catastrophic consequences of accidental spinal tranexamic acid injection, appears to be a timely reminder of this unsolved problem . Ever since the publication of the landmark WOMAN trial , tranexamic acid, an antifibrinolytic drug, has become an integral component in the treatment of postpartum haemorrhage.…”

“…Similar to the well‐known neurotoxicity of chlorhexidine , tranexamic acid is a potent neurotoxin. Spinal administration of tranexamic acid has a mortality rate of over 50%, and a high incidence of permanent neurological injury and paraplegia in survivors .…”